Influenza Preparedness in the Iran Petroleum Industry Health Organization

1. Influenza Preparedness in theIran Petroleum Industry Health Organization Bijan Hamidi, MD MPH Director of Strategic Studies and Performance Analysis office Member of the Disaster Task Force Secretary of the Influenza Epidemic Preparedness Task Force Petroleum Industry Health Organization (PIHO), Iran World Conference on Disaster Management Toronto, Canada June 2006 A deeper look into the process raher than the input

2. Layout of the presentation • Iran and the Ministry of Petroleum 3 • PIHO and its Mandate 7 • Impact of AF at the ministerial, national and global levels 9 • Challenges faced 15 • Development of a plan 18 • General overview of the plan 20 • Phases 21 • Case definitions 24 • ToRs 26 • Task Force and the liaisons 29 • Experts team 31 • specialized Medical Teams 32 • Organization Capacity Assessment 33 • Coordination 35 • Surveillance 36 • Training 38 • Program M&E, Research and documentation 39 Wherever needed, additional information is brought in the notes sheet

3. Iran • Located in the Middle East, joining South Asia to the Europe • More than 1.6 million sq km, 12000 sq km of water and almost 2500 km of coastline • Mostly hot dry climate, but also sub-tropical in the North • Dense poultry population in the North and West part of the country

4. Note: Original map from FAO, cases around Iran added later.

5. Petroleum Industry (1) • Iran economy depends heavily on the petroleum industry • Oil makes up to 80% of the country exports, 4th exporter of oil to the world • Oil, gas and petrochemical plants and firms, are the major industries in the country • More than 360 companies and 270 major industrial sites

6. Petroleum Industry (2) • Almost 100,000 work in the Ministry of Petroleum and another 60,000 in the associated companies • Most of these employees work in remote, oil and natural gas reach areas in South and South West of the country • Industrial plants including refineries and petrochemical firms are all around the country

7. Petroleum Industry Health Organization (PIHO)www.piho.ir • Is directly responsible for the health services of the Ministry’s employees and their families in the operational sites and also in the cities • Operates at the national level; 20 regional offices in the country • 9 hospitals, 19 dayclinics and polyclinics, more than 60 family clinics and 100 occupational health centers, all around the country

8. Petroleum Industry Health Organization (2) • More than 5,500 employees • All the specialty and sub-specialty curative services • But the focus is on the preventive and emergency care, especially in the operational sites • Also provides services to the local communities in remote areas of the country

9. The hovering threat • If a full scale AF pandemic occurs, leading to an epidemic in Iran, lasting for 4 months… • With an estimated attack rate of 30% in the first 3 to 4 months, • And a work absence rate of at least 25% at each point in the time… • Total work time lost will reach to 8,000 man-years and … • With 2% mortality, the work-force lost will be more than 8,700 man-years.

10. Impact of possible AF pandemic to the industry (1) • This will be equal to 330 m USD just based on average salaries and compensation rates • The 16,700 years of work force lost during the epidemic period is equal to 17% of the annual work force • This is expected to cause at least 10% (400,000 m BPD) reduction in Iran oil production equivalent to 3.12 b USD loss for the 4 months pandemic period based on present oil production and price rates1

11. Impact of possible AF pandemic to the industry (2) • This losses excludes: • Cost of reduction in petrochemical and gas production capacity • Cost of social disruption due to oil production and distribution failure • Cost of health system failure due to system overload • Cost of psychological and sociological trauma

12. Global impact • Following the Arabs – Israel war and the Arabs oil embargo in 1973, a net 4 m barrels/day reduction in oil production led to 400% increase in the oil price1 • If a direct relation is supposed, the oil production reduction in Iran per se, if not compensated, may contribute to 40% increase in global oil price • Still in another more optimistic scenario, decrease in Iran oil production may contribute to 12% increase in global oil price2

13. Impact of possible AF pandemic in PIHO (1) • With hospital admission rate of 50 percent and mortality rate of 2 percent: • PIHO is estimated to face 5-7 fold increase in hospital admissions and more than 25 fold increase in mortalities • This sharp increase in health services demand, is along with at least 30 percent reduction in health work force

14. Impact of possible AF pandemic to PIHO (2) • This sharp increase in health services demand, is along with at least 30 percent reduction in health work force • Leading to a complete disaster state in health care services

15. Challenges faced in PIHO • Sensitizing PIHO top level managers and development of a consensus within the organization for resource mobilization • Awareness raising and sensitizing the petroleum Minister and Boards of Directors of companies and firms

16. Awareness raising and sensitization (1) • Turned out to be the major challenge • Financial resources needed for key preparedness actions (i.e. vaccination, stockpiling of medications and education of the population) was the major factor contributing to the decision makers unwillingness for commitment • Awareness raising was particularly found to be inadequate when a key decision maker in the ministry wrote on the letter requesting support for the plan that “it seems unnecessary”!

17. Awareness raising and sensitization (2) • A campaign for awareness raising was started • Among many activities, the following were particularly found to be useful: • Participation in the Ministry of Petroleum Council of Deputies and meetings of Boards of Directors of the companies to discuss the threat and the consequences, face to face • Discussing the ongoing preparedness activities in other countries and industries • Bringing facts, reports and continuous news updates to the attention of the managers • And very interesting of all raising concerns in the families of the employees during daily clinical visits

18. Planning process • For different reasons (noteworthy of all, lack of adequate resources) the focus of the planning was on the process rather than the input • The planning process was initiated in June 2005 and a team was organized for this • The first draft was submitted in August • The plan was continuously improved by subsequent discussions and consultations; now in its fifth version • An orientation and training workshop (ToT) for the regions liaisons was conducted in November • Subsequent orientation workshops were conducted for the heath care workers in the regions

19. Objectives and expected outcomes • To reduce the avoidable causes of mortality and morbidity (in the population covered) due to possible epidemic of influenza in the country • To improve efficiency and effectivity of health interventions in a frenzy state of soaring demand and to avoid confusions • To ensure business continuity and reduce workforce absenteeism and loss • To contribute to the national and global efforts to control the pandemic

20. Components of the plan • Actions phase definitions • Case definitions • ToRs and job descriptions • Influenza Task Force • Experts team • Specialized Medical Teams • Organization Capacity Assessment • Intrasectoral and intersectoral coordination • Surveillance • Training • Operations M&E, research and documentation

21. Actions phase definitions • To get a clear view of what to do when • To avoid unnecessary actions and avoid delays in actions to be taken • Three phases were defined based on WHO 3 periods, 6 phases to address specific needs of the organization • According to this definitions, we are (were?) in the first phase • The distinction between phase 2 and 3 will be official confirmation of the first human case in the country

23. Back to the components page Phases and specific priorities • Phase I • Awareness raising and development of consensus • Planning and organization • Risk assessment • Development of intersectoral and intrasectoral coordination mechanisms • Vaccination and stockpiling of antiviral and other medicines and consumables • Training and capacity building • Medical examinations on return from abroad • Phase II • Broadening of vaccination • Enhanced surveillance activities • Regular meetings of TF and Expert team • Level one safety administrative regulations (limitations on public gatherings, reporting symptoms, …) • Phase III • Provision of curative care • Control measures for the Epidemic • Level two safety administrative regulations (social gatherings banned, meetings frequency and participation reduced to the minimum, out of office working,…)

24. Case definitions • An absolute need to reasonably identify and assign cases so that to • Avoid over-reactions and at the same time, life threatening delays in appropriate actions to be taken • The traditional categorization of the cases into suspected and definite cases in the surveillance systems, appeared to be insufficient to address the bursting nature of flu epidemic coarse • Before a case is diagnosed as a suspicious case to be reported, it may be assigned as a case to be closely followed up by local staff if certain sign and symptoms are observed • At the same time the definition of cases, extremely depends on the phases of the epidemic/ pandemic • In the surveillance and health care system, these cases are treated appropriately

25. Back to the components page Case definitions

26. Terms of Reference and job descriptions • The key factor to ensure a swift and effective health response is clear and specific actions for health staff, either the managers or the staff directly involved in patient care • This also depends on the phase of the epidemic • These ToRs are developed for GPs and Family Physicians, specialists, Directors of the regional offices, Hospital directors, Directors of the occupational health centers, regional directors of occupational health, regional flu liaisons, the organization deputies, members of the flu Task Force and even the President of the organization

27. Overview of individuals main tasks • GPs and family physicians to be involved in direct observation and care of the cases, • Specialists to provide specific care, especially to the critical cases • Managers at all levels to take care of the staff safety and health, and to ensure and monitor coordinated, supported response • Occupational health managers to be directly involved in care of the employees regarding public health issues at work and absenteeism • Regional Flu liaisons to ensure vertical information sharing, situation reporting, and performance monitoring in the regions

28. Back to the components page Sample action sheet

29. Influenza epidemic preparedness and response Task Force • A task force is formed as the highest body to govern the preparedness and response of the organization • The President of the organization works as the head of the TF. The secretary is in charge of the coordination and follow up of the issues (members listed in the slide note sheet) • All the members have clear and specific ToRs

30. Back to the components page Task Force main responsibilities • To ensure health staff safety against influenza while in service • Governing, leadership, coordinating, prioritizing, and decision making during flu preparedness and response • Trend analysis and predicting short and long term effects of the pandemic on the petroleum industry • Providing resources and taking care of the gaps • Coordination with the national partners in the preparedness and response • Accountability against the Ministry of Petroleum and informing the media

31. Back to the components page Influenza expert team • Is the technical and consultative body of the Flu TF • Members include distinguished experts in infectious. Pulmonary and ICU specialists, Internists, Pediatricians, anesthesiologists and epidemiologists. • One of their main tasks is to develop ICU and hospital admission policies appropriate at each point of the crisis

32. Back to the components page Specialized Medical Teams • Designed to act upon observation of first cases (in all the hospitals) • Specially trained and fully protected to work as the first line of inpatient care for influenza cases • When cases are abandoned and involvement of the whole medical staff is required, teams are increased and they are divided into that teams, later may work as supervisors and specialized care givers

33. Capacity assessment of the Regional Offices • A major component of risk assessment • A detailed form was developed to assess the situation of the 20 regions regarding: • Vaccination and population education capacities • Outpatient and inpatient capacities at regular times and in case of surge in demands (Isolated and ICU beds, ventilators,…) • Human resources with related expertise • Logistic capacities, transportation, storage, communications, public relations • Level of coordination with local MoH, and other partners • Capacities for indirect services (outsourcing) • Resources in the industry that can be mobilized in case of crises situations

34. Back to the components page Objectives of the capacity assessment • Particularly directed to identify strengths and weaknesses based on the plan • So that gaps are recognized, prioritized and addressed accordingly • Fine tuning of the plan based on realities on the ground • And to assess managerial capacities to handle crises situations

35. Back to the components page Intrasectoral and Intersectoral Coordination • Success in achieving the goals of the plan could only be viewed in terms of effective intrasectoral and intersectoral partnership • The priority of the global and national actions to the components of this plan is emphasized and encouraged to be respected, unless a gap or failure is noticed • Close collaboration of PIHO Regional Offices with local MoH and other partners is encouraged and emphasized in the plan • Rigorous coordination meetings and information exchange is mandatory with all the partners

36. Surveillance • The hallmark of a quick, effective, dynamic response to a variety of possible scenarios during an epidemic • Designed to be effective and at the same time as simple as possible so that it can be managed during a crisis and chaos situation • Forms developed for registering and report of different cases by related staff

37. Back to the components page Surveillance Objectives • To monitor the epidemiologic situation of the epidemic and if needed to consider change of phases • Early diagnosis and secondary prevention of Influenza cases • Follow up of the cases for health outcomes evaluation and monitoring of efficacy of medical interventions • To reflect case load and burden of disease for appropriate managerial decisions • Timely identification of shortage of resources and broadening gaps in the services in the Regions • Documentation

38. Back to the components page Trainings and mock drills • Capacity building among health care workers and even managers is the main factor to ensure automatic appropriate reactions to the rapidly evolving situation in crises • For this reason, extensive efforts was put on preparing training material, holding workshops at the national and regional levels, encouraging participation in online training courses and most important of all for planning mock drills.

39. Back to the components page Operations Monitoring & Evaluation, Research and Documentation • As a integral part of the plan, specific measures are taken to ensure appropriate monitoring and documentation so that lessons are not missed • A major responsibility of the communication and Media Officer in the Task Force is arrange for appropriate documentation of the whole preparedness and response activities • The real situation will provide the best opportunity to test the efficacy of the plan to improve in continuously, if only we do not miss the lessons

40. Thank you for your time • All the plan document is in the process of translation into English and will be launched on the organization site at: • www.piho.ir/en/ • The author welcomes recommendations and exchange of information and experience, • Bijan Hamidi, M.D M.P.Hhamidi@piho.orghamidib@gmail.comMobile: (+98) 912 387 3488Office: (+98) 21 8894 2060